THE RESULTS OF PHALLOPLASTY DISCUSSION 1. General result

of phalloplasty. The inside layer of the ALTF was used for urethral reconstruction. Debris removal, pus drainage, antibiotic supplementation were used daily. The condition improved daily, with one third of the distal urethra was left opened.

4.3. THE RESULTS OF PHALLOPLASTY DISCUSSION

According to the study by Giulio Garaffa at al (2011), the aim of phalloplasty to achieve cosmetic acceptable results. However, the concept of beauty depends on society, race, culture, and religion.

Therefore, our score is based on doctor and patient’ perception of acceptable penis size (the phalloplasty size must be at least equal to an everage Vietnamese’s penis size) in oder to evaluate for the cosmetic phalloplasty. Our result showed that 22 (78.6%) phalloplasties are considered cosmetically acceptable.

Phalloplasty size - Phalloplasty length

According to the study by Mondaini. N at al (2002), the adult penis length is from 8.9 to 10.7 cm in a flaccid condition, and from 12.5 to 16.7 cm in an erectile condition. Our study show that the totally average phalloplasty length is = 11.3 ± 1.5 cm.

Therefore, our phalloplasty is within the normal range of a healthy penis length.

- Phalloplasty circumference

+ Penile reconstruction with ALTF only, n = 26

Ponchietti R at al studied 3300 people between 17-19 years of age in 2001 reported that flaccid penile circumference (on mild trunk) is 10 cm, erectile penile circumference is 12.5 cm. According to the study by Nguyen Tan Gi Trong (1975), the average Vietnamese’s penes circumference (on mild trunk) is 8.0 ± 0.4 cm. Our study shows that the average phalloplasty circumference is 10.3 ± 0.6 cm in 4 cases of total penectomy, and is 11.2 ± 0.9 cm in 22 cases of partial penectomy. Therefore, phalloplasty circumference seen in our study is matches to the Westerners penes circumference, and is considered at being at a larger size than the Vietnamese counter part.

+ Penile reconstruction with ALTF + scrotal skin, n = 2

Phalloplasties are 9.2 cm and 9.8 cm. Phallolasty length are 11.0 cm and 11.5 cm. Hence, phalloplasty length is matched to a normal penile length. Although phalloplasty circumference in the event of combining ALTF with a scrotal skin is smaller than the one using ALTF only, it is still larger than the average Vietnamese’s penes cicumference.

Urethroplasty result

89.3% of urethroplasty (25 phalloplasties) was reconstructed completely as a skin tube. 2 urethroplasties were kept open distally because of a necrotic ALTF (an urethroplasty with the distal one third of the urethral kept open and one with the distal half of the urethral kept open). A curved urethroplasty is typically resulted from a scar contracture, which is typically seen with necrotic ALTF. The necrotic ALTF was then removed, with the defect covered by the graft.

Consequently, the graft contracture resulted in a curve urethroplasty.

At any time when he urinates, he have to goose penis upward to have a urinary stream deflecting downward.

Reconstruction of penile trunk using ALTF + scrotal skin: both the skin colour and penile shape obtained optimal cosmetic results because the phalloplasty skin was similar to normal penile skin; however, the functional penis is not optimal due to the soft phalloplasty.

Reconstruction of penile trunk with ALTF only: 82.1% of phalloplastic trunk (23 phalloplasties) are totally reconstructed.

Phalloplastic trunk is a semi-real (with fake skin in the inside and real skin on the outside).

Glanoplastic result

21 glans (67.7%) were reconstructed using the Norfolk technique.

The average glanoplastic length was 2.8 ± 0.4 cm (the longest glanoplasty is 3.5 cm, the shortest glanoplasty is 2 cm). 2 glans (6.5%) were reconstructed by the mushroom flap in the distal ALTF.

The glanoplastic length was 2.2 cm, and 3.5 cm, respectively. 8 (25.8%) patients required no glans reconstruction. There is no report about penile length that is in concordance with the urethral length;

therefore, we did not have any objective measurement for the glanoplastic length. However, in our experience, glanoplasty helps to contour phalloplasty achieve a more acceptable cosmetic outcome.

Coronal appearance can not be achieved with glans reconstruction using the musroom flap in ALTF. Coronal appearance obtains cosmetically acceptable outcome in 76.2% and unacceptable outcome in 23.8% of glanoplasty using the Norfolk technique.

4.3.2.2. The functionally phalloplastic results Sensitive nerve restoration

- Sensitive nerve restoration among 26 phlloplasties with ALTF only

Several reports including Zayed E. at al (2004), Mamoon Rashid at al (2011) demonstrated sensitive nerve restoration on phalloplasty when a nerve anastomosis was done. The obvious is that sensitive nerve restoration on phalloplasty could not be achieved without nerve anastomosis. However, our study confirmed that sensitive nerve restoration was always present in phalloplasty whether or not nerve anastomosis was done. 26 (80.8%) phalloplasties achieved a complete nerve restoration (S4), 5 (19.2%) phalloplasties achieved a partial sensitive nerve restoration (S2). A complete nerve restoration is defined as that all sensory types such as touch, pressure, pain and heat were preserved. A partial nerve restoration (S2) is defined as that either one or two of the following sensation was preserved.

- Sensitive nerve restoration among 2 phalloplasties reconstructed by ALTF combine with scrotal skin flap

A phalloplasty recovered a sensitive nerve restoration in a S2 grade.

Sensitive nerve (touch and pain) appeared on the trunk but none happened on the glanoplasty at 29 months follow-up. Another phalloplasty restored sensitive nerve completely (S4) after 15 months follow-up. Nerve anastomosis were not performed in 2 cases because no sensitive nerve in the scrotal skin was identified. However, sensitive nerve may be found in the pedicle scrotal skin, in this case, sensitive nerve restoration may be achieved from both the dorsal nerve and the scrotal skin.

The functionality of newly reconstructed penile in sexual intercourse

In 2009, Giulio Garaffa at al used radial forearm free flaps for phalloplasties in 15 patients following penile cancer resection. Of the seven patients who had penile prosthesis, five can engage in sexual intercourse. Our study showed that 5 out 6 phalloplasties had silicon bar penile implantation were able to engage in sexual intercourse. Nineteen out of the 22 patients (86.4%) who did not have implanted penile prosthesis were able to engage in sexual intercourse.

For these reasons, in term of sexual performance, ALTF is considered far better than radial forearm free flap.

The result of functional urethra

According to Mohan Krishna at al (2006), a patient was able to void urine standing through the neourethra after phalloplasty with

ALTF. Mamoon Rashid at al (2011) showed that 2 patients were able to urinate standing after one-stage nonmicrosurgical technique and 4 total phalloplasties with ALTF. Giulio Garaffa (2011) demonstrated that the aim of phalloplasty was to help patient void standing. We have found no consistent criteria to assess for functional urination; therefore, we decided on 3 criteria (urethral fistula or open, urinatting posture, and urethral stricture) to evaluate functional urination. According to these criteria, 89.3% of patients met the requirement of functional urination. 10.7% of patients did not meet requirement because of difficult urination, with opening of the distal urethral.

4.3.3. Late comlication and solution 4.3.3.1. Complicating category

Late complications were considered as events happened after discharge from the hospital or persistence after leaving the hospital.

21.4% (6 patients) had urethral stricture, 10.7% o (3 patients) had curved phalloplasty due to scar contracture. Opening urethra occurred in a patient because of complete urethral stricture between the native and neourethra, so we had incised a hole for urine drainage.

4.3.3.4. Complicating treatment Treatment of urethral stricture

Dilation: 5 urethral stricture were dilated using a dilator ranging from a small to large size. Finally, a Foley 14F was inserted into the bladder at the site of urethral stricture in order to prevent stricture relapse. Patients were offered to return in 10 days to have it dilated again if foley was not available.

Scrotal skin: a urethral stricture was seen 6 months postop.

Location of urethral stenosis was opened and the defect was covered by an island scrotal skin. Urethra was blocked completely on April 2013, so we created a small hole to drain urine. The urethral stenosis was closed directly on February 2014. After that time, he was able to void normally while standing.

Curved phalloplasty

A Z - plasty was used to correct a curved phalloplasty, but the procedure was not successful. Two other curved phalloplasties did not completely close the deformity.

4.4. ADVANTAGES AND DISADVANTAGES OF ALTF